Agreement Between Transthoracic Echocardiography and Digital Subtraction Angiography for the Detection of Right Atrial Thrombus in Patients Undergoing Maintenance Hemodialysis: A Retrospective Cohort Study
Aug 2026· Journal of Clinical Medicine· Vol 15· 0 citations· 15 references
Medicine
TL;DR
TTE is recommended as the first-line CRAT screening tool for MHD patients and combined TTE and DSA use improves diagnostic yield, and regular targeted surveillance for high-risk individuals reduces CRAT incidence.
Abstract
Background/Objectives: Patients on maintenance hemodialysis (MHD) have an increased risk of catheter-related right atrial thrombosis (CRAT) due to long-term central venous catheterization. Transthoracic echocardiography (TTE) and digital subtraction angiography (DSA) are commonly used to evaluate right atrial thrombi, yet their diagnostic consistency in this patient population remains unclear. This study aimed to compare TTE and DSA diagnostic agreement for CRAT and explore its independent risk factors. Methods: We retrospectively enrolled 254 MHD patients who underwent paired same-day TTE and DSA from November 2021 to May 2025. Cohen’s kappa, intra-class correlation coefficient (ICC), and Bland–Altman analysis were used to evaluate diagnostic consistency. Univariable and multivariable logistic regression screened independent CRAT risk factors. Results: The thrombus detection rates of TTE and DSA were 17.3% and 14.6%, respectively, with moderate diagnostic consistency (κ = 0.487, p < 0.001). The ICC values were 0.871 for thrombus length and 0.824 for thrombus width between TTE and DSA, indicating excellent consistency in thrombus size measurement between the imaging modalities. Catheter tip located in the mid-right atrium, decreased central venous catheter flow, prolonged catheterization, and male sex were independent risk factors for CRAT. The predictive model exhibited good discrimination (area under the curve = 0.788) and acceptable calibration (Hosmer–Lemeshow, p = 0.429). The optimal cutoff derived from the Youden index was 0.191, with a corresponding sensitivity of 81.0% and specificity of 67.3%. Conclusions: TTE is recommended as the first-line CRAT screening tool for MHD patients. Combined TTE and DSA use improves diagnostic yield. Regular targeted surveillance for high-risk individuals reduces CRAT incidence.
CT-derived AVA demonstrates strong agreement with TTE and provides complementary information for severity assessment and risk stratification in patients with aortic stenosis, particularly in cases with discordant or borderline findings.
Shehroz Sultan, Neeraj Joshi, A. H. Awan et al.· Journal of Community Hospita...· 0 citations
Background Transesophageal echocardiography (TEE) is the reference standard for excluding left atrial thrombus (LAT) in rheumatic severe mitral stenosis (SMS), yet its availability is limited in many low-resource settings. A reliable, low-cost strategy to safely defer TEE would have a significant clinical impact. This study evaluated whether D-dimer–based predictive models can accurately exclude newly detected LAT in treatment-naïve patients with rheumatic SMS. Methods Sixty-eight consecutive patients with rheumatic SMS who were not receiving anticoagulation underwent D-dimer testing, transthoracic echocardiography, and TEE. Associations with LAT were assessed using conventional and Firth-penalized logistic regression. Diagnostic performance was evaluated using receiver operating characteristic analysis with 1,000-bootstrap internal validation. Two composite models were examined: D-dimer combined with atrial fibrillation (AF) and D-dimer combined with mitral valve area (MVA). Results LAT was newly detected in 12 patients (17.6%). D-dimer levels were significantly higher in LAT-positive patients (943.5 vs. 168.5 ng/mL, p < 0.001). The optimal D-dimer cut-off (360.6 ng/mL) achieved 100% sensitivity, 71.4% specificity, and an optimism-corrected AUC of 0.935, outperforming the conventional 500 ng/mL threshold (sensitivity 75%). In adjusted models, D-dimer remained a strong independent predictor of LAT (per SD: AOR 6.91; 95% CI 2.72–17.54). Composite models demonstrated similarly high discrimination (AUC 0.933–0.940); adding AF did not improve performance, whereas incorporating MVA increased specificity to 100%. Conclusions D-dimer may help exclude LAT in treatment-naïve patients with rheumatic SMS. Its potential role in supporting more selective TEE use in resource-limited settings warrants further evaluation in larger prospective multicenter studies.
N. Al-Wather, Mohammed M Al-kebsi, Abdulhafeedh Al-Habeet et al.· Frontiers in Cardiovascular...· 0 citations
BACKGROUND
Accurate preprocedural imaging is essential for left atrial appendage occlusion (LAAO) device sizing. Although cardiac CT angiography (CCTA) is widely used, radiation and contrast limit its use.
PURPOSE
To assess non-contrast cardiac MR (CMR) for LAAO planning by comparing measurements with CCTA and digital subtraction angiography (DSA), evaluating agreement with implanted device size, and predicting optimal fluoroscopic projection angles (OPA).
MATERIALS AND METHODS
Thirty-two patients with atrial fibrillation scheduled for LAAO (April 2024-October 2025) underwent non-contrast CMR and CCTA before DSA. Landing zone dimensions and morphology were assessed using identical 3D multiplanar protocols. Area-derived equivalent diameter was used for sizing. OPA predicted by CMR and CCTA were compared with DSA. Agreement with final device size was analyzed using Bland-Altman plots.
RESULTS
Thirty patients (mean age 66.9 years) completed both exams; LAAO succeeded in 29 (96.7 %). CMR and CCTA showed no significant differences in landing zone measurements (area: 521.2 ± 210.0 vs 523.9 ± 225.9 mm2,p = 0.759; area-derived diameter: 25.3 ± 5.1 vs 25.5 ± 5.4 mm,p = 0.475). DSA maximum diameter was smaller than direct CMR/CCTA diameters (p < 0.05) but similar to area-derived diameters (p = 0.355). CMR area-derived diameter closely agreed with device size (bias - 2.76 mm; limits - 6.97 to 1.45 mm), comparable to CCTA. Predicted OPA from CMR agreed with DSA and CCTA.
CONCLUSION
Non-contrast CMR provides measurements and OPA prediction comparable to CCTA, supporting its feasibility as a radiation- and contrast-free alternative for selected patients.
Qing-song Wang, Jie Bao, Meng-Lu Li et al.· European Journal of Radiolog...· 0 citations
BACKGROUND
Intracardiac echocardiography (ICE) is a valuable, real-time imaging tool in structural cardiology and electrophysiology, performed without general anesthesia. However, its safety compared to transesophageal echocardiography (TEE) remains unclear.
OBJECTIVE
To conduct a meta-analysis evaluating outcomes of catheter ablation for atrial fibrillation (AF) with or without left atrial appendage closure (LAAC) guided by TEE versus ICE.
METHODS
Databases were searched for studies comparing ICE with TEE guidance during AF ablation ± LAAC. Outcomes were pooled using the Inverse-Variance (IV) random-effects model in R, with risk ratios (RRs) for dichotomous variables and mean or standardized mean differences (MD or SMD) for continuous variables, and 95% confidence intervals (CIs) reported.
RESULTS
We included 8 studies involving 7,671 patients, of whom 3,903 (50.9%) underwent procedures with ICE guidance. There were no significant differences between groups in cardiac tamponade risk (RR 0.86; 95% CI 0.44-1.66; p = 0.39), stroke or TIA (RR 1.00; 95% CI 0.39-2.55; p = 0.57), vascular complications (RR 0.80; 95% CI 0.51-1.25; p = 0.37). ICE was associated with lower pre-procedure LAA thrombus detection (RR 0.32; 95% CI 0.11-0.94; p = 0.04), radiation dose (SMD -0.47; 95% CI -0.90 to -0.04; p = 0.03), and fluoroscopy time (-4.25 mins; 95% CI -6.01 to -2.49; p < 0.01) but the procedure duration was significantly lower only in combined AF ablation + LAAC (MD -19.56 mins; 95% CI -24.15 to -14.97; p < 0.01).
CONCLUSION
This meta-analysis indicates that ICE is a safe, effective, and non-inferior alternative to TEE for patients undergoing AF ablation ± LAAC. However, TEE remains an effective tool for detecting LAA thrombus.
M. Dandamudi, B. Hakkeem, Juan Pinilla et al.· European Heart Journal-Cardi...· 0 citations
Routinely available ECG-derived P-wave dispersion and echocardiographic LAVI are independent, complementary predictors of MACE in CAD patients, and integrating these two parameters into a simple risk model significantly enhances risk discrimination and reclassification, providing a practical, cost-effective tool for individualized management.
Qin Wu, Gang Chen, Jian Chang· Frontiers in Medicine· 0 citations
Background Evidence regarding the link between imaging modality and stroke prevention outcomes of left atrial appendage occlusion is currently lacking. Methods The RECORD (Registry to Evaluate Chinese Real‐World Clinical Outcomes in Patients With AF Using the WATCHMAN Left Atrial Appendage Closure Technology) trial prospectively enrolled 3096 consecutive patients undergoing left atrial appendage occlusion from 39 Chinese centers between April 1, 2019, and October 31, 2020. In the current analyses, patients were stratified into the echocardiographic guidance (transesophageal echocardiography/intracardiac echocardiography) group and the fluoroscopy‐only group. The primary end point was the composite end point of death, stroke, or systemic embolism at 3 years. Outcomes were estimated using the Kaplan–Meier method. Inverse probability of treatment weighting and 1:1 propensity score matching were performed to calculate hazard ratios (HRs) for each outcome at the time of interest. Results Among 3096 participants, 2603 (84.1%) underwent transesophageal echocardiography/intracardiac echocardiography–guided procedures and 493 (15.9%) underwent fluoroscopy‐only guided procedures. Before discharge, procedural complications occurred in 34 patients (1.4%) in the transesophageal echocardiography/intracardiac echocardiography group and 3 patients (0.6%) in the fluoroscopy‐only group (inverse probability of treatment weighting–adjusted absolute difference, −0.67 [95% CI, −1.39 to 0.05], P=0.066). At 3‐year follow‐up (completed by 2989 patients, 97.0%), the primary end point occurred in 269 (10.5%) patients in the transesophageal echocardiography/intracardiac echocardiography group and 52 (10.6%) patients in the fluoroscopy‐only group (inverse probability of treatment weighting–adjusted HR, 1.13 [95% CI, 0.81–1.57], P=0.469). Ischemic stroke was comparable between groups (3.0% versus 4.1%, inverse probability of treatment weighting–adjusted HR, 1.66 [95% CI, 0.95–2.89], P=0.073). These findings remained consistent across patient risk profiles and operator experience levels. Conclusions Fluoroscopy‐only guidance, without compromising long‐term stroke prevention efficacy, may serve as a streamlined and potentially accessible alternative for left atrial appendage occlusion procedures performed with the first‐generation WATCHMAN 2.5 device, and these findings apply to select patients and experienced centers. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03917563.
Ping Wang, Zhengquan Chen, Yongmeng Yan et al.· Journal of the American Hear...· 0 citations
